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Minimally Invasive Repair of Pectus Carinatum

Video Published 2019-11-26 Updated 2026-08-01

Timestops (3)

Patient Selection and Anesthesia Setup

Subperiosteal Rib Dissection and Cable Placement

Bar Deployment and Correction Results

Topic Overview

This is a surgical technique demonstration of minimally invasive repair of pectus carinatum (the Abramson or reverse Nuss procedure) performed on two 16-year-old boys with moderate chest wall stiffness (correction pressures 6-7 PSI). The procedure uses a pectus bar anchored to four ribs via subperiosteal cable fixation with rib protectors, avoiding cartilage resection. One-year postoperative results showed excellent correction maintenance with lateral chest wall expansion.

Key Takeaways

Minimally invasive pectus carinatum repair avoids cartilage resection using bar fixation to four ribs. (0:08)
Correction pressures of 6-7 PSI indicate moderate chest wall stiffness suitable for this technique. (0:27)
Subperiosteal cable fixation with rib protectors prevents cables from cutting through ribs during healing. (4:32)
One-year outcomes show maintained correction plus lateral chest wall expansion beyond initial deformity repair. (4:48)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1

Chapters

0:00Introduction and Patient Selection — Overview of pectus carinatum correction options, description of the minimally invasive technique, and presentation of two 16-year-old patients with moderate chest wall stiffness who chose this approach.
1:11Surgical Preparation and Initial Dissection — Patient marking, bar sizing, incision placement, and subperiosteal rib dissection technique.
2:22Rib Protector and Cable Placement — Placement of bendable rib protectors with cables in subperiosteal spaces, threading through stabilizers, and labeling for future removal.
3:27Bar Placement and Fixation — Tunnel creation, bar insertion, cable tightening with pioneer system, and achievement of correction with four-point rib fixation.
4:36Closure and Results — Layered closure, postoperative imaging, and one-year follow-up showing maintained correction and lateral chest wall expansion.

Key claims

0:00Pectus carinatum can be corrected by a number of surgical and non-surgical techniques — Speaker 1
0:08Minimally invasive repair of pectus carinatum (Abramson or reverse Nuss procedure) can correct the pectus without cartilage resection — Speaker 1
0:27Correction pressures between 6 and 7 pounds per square inch indicate moderate stiffness of the chest wall — Speaker 1
0:58The procedure is performed under general anesthesia with an epidural catheter for intraoperative and postoperative analgesia — Speaker 1
1:05Prophylactic antibiotics are given and a Foley catheter is inserted and kept for 24 hours — Speaker 1
1:19The bar length is chosen equal to the distance between the two mid-axillary lines at the highest point of the carinatum after correction — Speaker 1
1:57Ribs are cleared of all muscle attachments for a distance of approximately 3 centimeters — Speaker 1
2:13A 1 inch periosteal incision is made in the rib and the periosteum separated from the underlying bone anteriorly and posteriorly — Speaker 1
2:58A small piece of dental wire is used to label the rib protector to facilitate removal from behind the rib in 2 to 3 years — Speaker 1
4:24The bar is tightly anchored to 4 ribs, 2 on each side — Speaker 1
4:32The rib protectors prevent the cables from cutting through the ribs — Speaker 1
4:48One year after repair, excellent correction was achieved and maintained — Speaker 1
4:55In addition to correction of the pectus, lateral chest wall expansion occurred — Speaker 1

Cases discussed

0:19Two 16-year-old boys with pectus carinatum onset at adolescence, moderate chest wall stiffness, treated with minimally invasive repair

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Minimally Invasive Pectus Carinatum Repair: Compression Without Cartilage Resection

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Approach Exists

Pectus carinatum — the protrusion deformity where the sternum and costal cartilages bow outward — has traditionally been corrected either by external bracing (for compliant patients with flexible chest walls) or by open cartilage resection procedures that require substantial dissection and recovery time 0:00. The minimally invasive repair, also called the Abramson or reverse Nuss procedure, emerged as a third option: internal compression using a substernal bar and cable system to remodel the chest wall without removing cartilage 0:08. It occupies the middle ground between bracing (which requires extended daily wear) and open resection (which involves significant tissue disruption) 0:00 0:08.

The Core Clinical Problem

Pectus carinatum correction requires sustained inward pressure to remodel cartilage and bone over time 0:08. The chest wall must be compressed enough to achieve correction but not so aggressively that hardware cuts through ribs or causes ischemic injury 4:32. The challenge is anchoring a compression system securely to ribs that are themselves part of the deformity, maintaining that correction for years, and then removing the hardware without major dissection 0:08 2:58.

How the Technique Works

The procedure uses a curved substernal bar — the same hardware designed for pectus excavatum repair — but applies it in reverse: instead of lifting a depressed sternum outward, it compresses a protruding sternum inward 0:08. The bar sits against the anterior chest wall, anchored to four ribs (two on each side) via cables that loop around the ribs within the subperiosteal space 4:24.

Bar sizing is determined by measuring the distance between the mid-axillary lines at the highest point of the carinatum after manual correction — essentially, the bar length matches the width of the corrected chest 1:19. Incisions are placed laterally in the intercostal space between the two ribs that will serve as anchor points 1:57. Ribs are cleared of muscle attachments for approximately 3 centimeters, then a one-inch periosteal incision is made and the periosteum separated from underlying bone both anteriorly and posteriorly 1:57 2:13.

The critical technical element is the rib protector: a bendable metal plate that sits between the cable and the rib within the subperiosteal space 4:32. The cable is threaded through holes in the protector, then both are passed under the rib 4:32. The protector distributes cable tension across the rib surface, preventing the cable from cutting through bone under sustained compression 4:32. Each protector is labeled with a small piece of dental wire at the time of placement to facilitate identification and removal in two to three years 2:58.

Once all four rib protectors and cables are positioned, the bar is tunneled across the anterior chest wall and the cable ends threaded through a four-hole stabilizer on each side 4:24. The cables are then tightened using a crimping system while manual pressure is applied to the chest to achieve the corrected position 4:24. The crimps lock on the anterior surface of the stabilizer, creating a four-point fixation system that holds the chest wall in the corrected configuration 4:24.

The procedure is performed under general anesthesia with epidural analgesia for intraoperative and postoperative pain control 0:58. Prophylactic antibiotics are given and a Foley catheter maintained for 24 hours 1:05.

Patient Selection

The technique is applicable to patients with moderate chest wall stiffness 0:27. In the cases described, correction pressures measured between 6 and 7 pounds per square inch, which the discussant characterizes as moderate stiffness 0:27. This measurement appears to guide selection: patients with very flexible chest walls might be better served by bracing, while those with rigid deformities might require open resection 0:00 0:27. The patients in this series were adolescent males who chose this approach after being informed of all options 0:27.

Outcomes and Remodeling

At one-year follow-up, correction was achieved and maintained 4:48. Notably, one of the discussants observes that lateral chest wall expansion occurred in addition to correction of the central protrusion 4:55. This suggests the compression system allows some degree of chest wall remodeling rather than simply flattening the deformity — the rib cage appears to redistribute volume laterally as the anterior protrusion is reduced 4:55.

When to Involve This Team

Referral is appropriate for adolescent or young adult patients with pectus carinatum who have failed or declined bracing and are seeking surgical correction 0:00 0:08. The minimally invasive approach is likely most suitable for patients with moderate chest wall stiffness — neither so flexible that bracing would suffice nor so rigid that cartilage resection becomes necessary 0:00 0:27. Patients should be counseled that hardware will remain in place for two to three years and that a second procedure will be required for removal 2:58. The technique requires familiarity with substernal tunneling, cable fixation systems, and management of hardware-related complications, so referral to a center with experience in both pectus excavatum and carinatum repair is appropriate 0:08 4:24.

Takeaways from this story

The reverse Nuss technique compresses pectus carinatum inward using a bar and cable system, avoiding cartilage resection entirely.
Bendable rib protectors placed in the subperiosteal space prevent cables from cutting through ribs under sustained compression.
Correction pressures of 6-7 PSI indicate moderate chest wall stiffness, a key factor in selecting patients for this approach.
At one year, correction is maintained and lateral chest wall expansion occurs, suggesting true remodeling rather than simple flattening.
Hardware remains in place for 2-3 years, requiring a second procedure for removal; dental wire labels facilitate later identification.

Minimally Invasive Pectus Carinatum Repair: Technical Execution Without Cartilage Resection

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

The Abramson procedure repositions the anterior chest wall through compressive bar fixation rather than cartilage excision 0:00, and its success depends on precise execution of several interdependent technical steps.

Correction pressure predicts technical difficulty and guides patient selection. Pressures between 6 and 7 pounds per square inch indicate moderate chest wall stiffness—a range where minimally invasive repair is feasible but requires secure four-point fixation 0:27. This measurement, taken during preoperative assessment, determines whether the deformity can be corrected with external compression alone or requires operative intervention 0:18. Patients with higher correction pressures may not be candidates for this approach, though the discussant does not specify the upper threshold.

Bar length is determined after manual correction, not from the native deformity. The bar must equal the distance between mid-axillary lines measured at the carinatum's highest point after the chest wall has been manually compressed to the desired position 1:19. Measuring the uncorrected deformity will yield a bar that is too long, failing to maintain adequate compression 1:19. The bar ends must align precisely with the intercostal spaces where the stabilizers will anchor—typically spanning two ribs on each side 4:24.

Subperiosteal dissection creates a protected pathway that prevents hardware failure. After clearing muscle attachments for approximately 3 centimeters, a 1-inch periosteal incision allows separation of periosteum from bone both anteriorly and posteriorly 1:57 2:13. The rib protectors and cables sit within this subperiosteal envelope 2:13. This is not simply a matter of placing hardware beneath the rib—the periosteum must remain intact around the protector to prevent the cables from cutting through bone under sustained compression 4:32. The discussant emphasizes that rib protectors alone are insufficient without proper subperiosteal positioning 4:32.

Hardware retrieval planning begins at the index operation. A small piece of dental wire labels each rib protector at the time of placement, allowing identification behind the rib when the hardware is removed in 2 to 3 years 2:58. Without this marker, locating and extracting the protectors from the subperiosteal space becomes significantly more difficult 2:58. This detail reflects experience with the removal operation—the discussant has clearly encountered the problem of unmarked hardware.

Four-point fixation distributes compressive force and prevents bar migration. The bar anchors to four ribs total—two on each side—using cables threaded through stabilizers 4:24. Each cable passes through a rib protector, around the rib within the subperiosteal space, and through two holes in the stabilizer 4:24. The Pioneer cable system allows tensioning while maintaining manual compression of the chest wall, then locks the crimps on the anterior surface of the stabilizer 4:24. Single-point or two-point fixation would concentrate force and risk hardware displacement.

Lateral chest wall expansion is an expected outcome, not just midline correction. One year postoperatively, both patients demonstrated not only resolution of the carinatum but also lateral chest wall expansion 4:55. The discussant presents this as a consistent finding rather than an incidental observation, suggesting that the compressive remodeling affects the entire anterior thorax 4:55. Whether this expansion improves pulmonary function or is purely cosmetic remains unaddressed, but the discussant clearly considers it part of the intended result.

The procedure requires epidural anesthesia for intraoperative and postoperative pain control, prophylactic antibiotics, and a Foley catheter maintained for 24 hours 0:58 1:05. The discussant presents these as standard elements rather than optional considerations—pain control in particular appears critical to preventing patient movement that could displace the hardware before tissue ingrowth stabilizes the construct.

Takeaways from this story

Bar length must be measured after manual correction of the deformity, not from the native chest wall configuration
Subperiosteal placement of rib protectors prevents cable cutting through bone under sustained compression
Dental wire markers placed at index operation facilitate hardware identification during removal at 2-3 years
Correction pressures of 6-7 PSI indicate moderate stiffness suitable for minimally invasive repair
Lateral chest wall expansion occurs in addition to midline correction and is an expected outcome

Minimally Invasive Pectus Carinatum Repair Without Cartilage Resection

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Case narrative · AI-written, human-reviewed

Presentation

Two 16-year-old boys presented with pectus carinatum that had developed at adolescence 0:00. Preoperative assessment measured correction pressures between 6 and 7 pounds per square inch, indicating moderate stiffness of the chest wall 0:27. After discussion of all available surgical and non-surgical options, the patients and their families elected to proceed with minimally invasive repair 0:00.

The Decision Point

Pectus carinatum can be addressed through multiple approaches: bracing, open repair with cartilage resection, or minimally invasive techniques 0:00. The choice hinges on chest wall stiffness, patient age, deformity severity, and tolerance for hardware placement.

For these patients, the moderate stiffness measurement was the critical factor. Correction pressures in the 6-7 PSI range suggested the chest wall could be remodeled without cartilage removal, making them candidates for the Abramson technique — also called the reverse Nuss procedure 0:08 0:27. This approach uses a compressive bar anchored to the ribs to flatten the protrusion, avoiding the tissue resection required in traditional open repair.

The alternative would have been open repair with costal cartilage resection, which offers definitive correction but requires more extensive dissection and leaves larger scars. Bracing, while non-invasive, demands prolonged compliance and works best in younger patients with more flexible chest walls. The team chose the minimally invasive approach based on the patients' age, the measured stiffness, and their preference for avoiding cartilage resection.

What Was Done

The procedure was performed under general anesthesia with epidural catheter placement for intraoperative and postoperative analgesia 0:58. Prophylactic antibiotics were administered and a Foley catheter placed for 24 hours 1:05.

Bar sizing was determined by measuring the distance between the mid-axillary lines at the highest point of the carinatum after manual correction 1:19. Bilateral incisions were made, and ribs were cleared of muscle attachments for approximately 3 centimeters 1:57. A 1-inch periosteal incision was made in each rib, and the periosteum was separated from the underlying bone both anteriorly and posteriorly 2:13.

Cables and rib protectors were passed through the subperiosteal space beneath each rib. A small piece of dental wire was attached to each rib protector to facilitate identification and removal at the planned 2-3 year mark 2:58. The bar was secured using a four-point fixation system — two ribs on each side — with cables threaded through stabilizers and crimped under pressure to achieve correction 4:24. The rib protectors served a specific mechanical function: preventing the cables from cutting through the ribs under tension 4:32.

Outcome

At one year postoperatively, both patients demonstrated excellent correction that had been maintained 4:48. Beyond the intended flattening of the protrusion, lateral chest wall expansion was observed — a secondary remodeling effect not limited to the anterior deformity 4:55.

What This Case Changes

The transferable judgment is in the stiffness assessment. Correction pressure measurement provides an objective threshold for technique selection. Moderate stiffness — the 6-7 PSI range seen here — defines a zone where minimally invasive repair becomes viable without cartilage resection 0:08 0:27. Below that range, bracing may suffice. Above it, open techniques may be necessary.

The four-point fixation with subperiosteal cable placement represents a specific technical solution to the mechanical problem of maintaining compression without hardware failure. The rib protectors are not optional; they address the predictable failure mode of cables cutting through bone under sustained load 4:32. The dental wire labeling system anticipates the removal operation years in advance 2:58.

The lateral chest wall expansion observed at one year suggests the correction forces remodel more than the anterior protrusion alone 4:55. Whether this represents advantageous growth or simply redistribution of the deformity was not discussed, but it is a measurable change that should be tracked in longer follow-up series.

Takeaways from this story

Correction pressures of 6-7 PSI indicate moderate chest wall stiffness suitable for minimally invasive repair without cartilage resection
Four-point rib fixation with subperiosteal cables requires rib protectors to prevent hardware from cutting through bone under tension
Dental wire labeling of rib protectors at insertion facilitates hardware identification during removal at 2-3 years
Lateral chest wall expansion occurs alongside anterior correction, representing remodeling beyond the primary deformity

Keywords

pectus carinatum minimally invasive repair of pectus carinatum Abramson procedure reverse Nuss procedure subperiosteal dissection periosteal incision prophylactic antibiotics

Hashtags

#PectusCarinatum #ChestWallAnomaly #SurgicalTechniques #MinimallyInvasive #AbramsonProcedure #ReverseNus #GeneralAnesthesia #EpiduralAnalgesia #RibDissection #SurgicalCorrection #PostoperativeCare #ChestSurgery #PectusRepair #PatientSafety #SurgicalInnovation #Anesthesia #SurgicalEducation #MedicalTraining #PediatricSurgery #OrthopedicSurgery #ChestWallRepair #ChestWallDeformity

Transcript

Pus carinatum is a chest wall anomaly that can be corrected by a number of surgical and non-surgical techniques. Minimally invasive repair of pectus carinatum, also known as the Abramson or reverse Nus procedure, is an innovative technique that can correct the pectus without cartilage resection. The operations depicted in this video were carried out on 2 16-year-old boys who had onset of pectus carinatum at adolescence. Their correction pressures were between 6 and 7 pounds per square inch, indicating moderate stiffness of the chest wall. They and their families were well informed of. All options and chose to proceed with the minimally invasive repair. In addition to the Zimmer Biome pectus tray containing tunnelers and bars, the special equipment used in this procedure includes 4 hole stabilizers, bendable rib protectors, and the pioneer sternal cable system. The procedure is performed under general anesthesia with an epidural catheter for intraoperative and postoperative analgesia. Prophylactic antibiotics are given, and a Foley catheter is inserted and kept for 24 hours. The patient is marked as shown. A vertical line is drawn in the midline of the chest from sternal notch to xiphoid. The distance between the two mid-axillary lines at the highest point of the carinatum is measured after correction of the carinatum, and a bar of equal length is chosen. The bar is placed on the chest and its borders drawn. The end of the bar on each side should correspond to the intercostal space between the two ribs where the stabilizers will be anchored, here shown on the patient's right side. The markings on the left side are shown here, and the incision is again centered between the two ribs which have been labeled. The incision is taken through skin, subcutaneous tissue. And all muscle layers down to the ribs, which are cleared of all muscle attachments for a distance of approximately 3 centimeters. After rib dissection, the bar is again placed on the chest wall to confirm correct positioning. A 1 inch periosteal incision is made in the rib, and the periosteum separated from the underlying bone anteriorly and posteriorly. The subperiosteal dissection of both ribs on the right side is complete. A right angle clamp is placed in the subperiosteal space under the rib. A narrow measuring tape is brought under the rib to measure the space. A rib protector of similar size is bent to the shape of the rib, and a cable is threaded through its holes. The cable is grasped, and the cable and protector are passed under the rib within the subperiosteal space. Here we can see that the process has been completed for the lower rib where the cable and rib protector are already in place. A small piece of dental wire is used to label the rib protector to facilitate removal from behind the rib in 2 to 3 years. The two rib protectors and cables on one side of the dissection are now in position. The two ends of each cable are then threaded through the two holes on each side of the stabilizer. The stabilizer with all cables threaded is then positioned in the pocket previously created. A tunnel is then created between the muscles and the bony chest wall using a long curved clamp and finger dissection from both sides meeting at the midpoint. It's completed with the least curved pectus tunneler. A 2 silk is tied to the pectus bar which has been bent in preparation for bringing it across the tunnel. The ends of the bar are inserted into a stabilizer on each side. Sterner wire is placed around a notch in the bar just distal to the stabilizer to lock the bar and stabilizer in position. The cables are adjusted so that each limb is of equal length. The pioneer cable system is assembled for deployment. The cable ends are threaded through the crimps at the tip. They are then fed through the instrument and tightened. With pressure on the chest to achieve a corrected position, the crimps are locked on the anterior surface of the stabilizer. The same process is performed twice on each side, and once completed, the bar will be tightly anchored to 4 ribs, 2 on each side. The rib protectors prevent the cables from cutting through the ribs. Excellent correction has been achieved. The incision is closed in layers to obtain adequate covering of the hardware. The postoperative chest x-rays of both patients are shown here. Here we see the results one year after repair. Excellent correction was achieved and maintained. Notice that in addition to correction of the pectus, lateral chest wall expansion has occurred.

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